Provider Demographics
NPI:1033117445
Name:LEWIN, JACK ROY (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ROY
Last Name:LEWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-1530
Mailing Address - Fax:601-984-1531
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-1530
Practice Address - Fax:601-984-1531
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10322207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL178569Medicaid
MS220028560OtherMEDICARE RR
MSP00340883OtherMEDICARE RR
MSP01236759OtherRAILROAD MEDICARE
MSP00454188OtherRR MEDICARE
MS00121874Medicaid
4004816OtherBC OF TN
MSP00454188OtherRR MEDICARE
MS220028560OtherMEDICARE RR
MS512I220003Medicare PIN
MS220000137Medicare ID - Type Unspecified